SCS Continuing Education and Three Phase CEUs presents:

Anatomy and Radiography of the Wrist, Hand, and Fingers

Copyright 2006

Introduction:
Hello and welcome to this program from SCS Continuing Education! Education Knowledge is the key to success for ourselves and our patients. This easy-to-use point and click program allows you to navigate through text and visual aides designed to provide a comprehensive view of the material covered. Please feel free to contact Shane Smith at ceuarmy@yahoo.com if you have any questions. Course Abstract and Objectives: The objective of this home study course is to provide the learner with a computer based tutorial that will give them the means to learn the anatomy and radiography of the ankle, foot, and toes. A mastery test will be administered at the end of this home study course in order to ensure that competency of the material has been achieved.
All images and artwork used in this program were obtained or drawn by Shane Smith.

Anatomy and Radiography of the Ankle, Foot and Toes

by Shane Smith PTA, RT(R)

Copyright 2006

CHAPTERS:
Fundamentals of the Foot and Ankle...pg 5 Bony Anatomypg 11 Positioning..pg 20 Technical Guidelines..pg 34 MRI.pg 36 Common Clinical Findings... pg 44 Conclusion..pg 55 Test.. pg 56 References.. pg 57

Fundamentals of the Foot and Ankle

Fundamentals of the Foot and Ankle:

There are 28 bones and 25 joints in the foot and ankle complex. These structures are configured to accommodate the stability and mobility responsibilities of the foot and ankle on various surfaces during varying degrees of weight bearing.

Fundamentals of the Foot and Ankle:

The foot is divided into 3 categories; the fore foot (metatarsals and phalanges), mid foot (cuboid, navicular and 3 cuneiforms) and hind foot (talus and calcaneous).

Transverse tarsal joint mid foot Subtalar joint Tarsometatarsal joint

fore foot

mid foot

hind foot hind foot fore foot

Lateral foot
Note: The joints will be discussed later in the tutorial.

AP foot

Fundamentals of the Foot and Ankle:

Now that we have been oriented to the basic structure of the foot and ankle, lets review the keys concepts related to motion. This section is split into two sections: joint classification and the arch. Lets begin by reviewing some terminology that will be used in the forthcoming slides. synovial joint: diathrotic; allows one or more types of free movement; contain articular cartilage, synovial fluid, synovial membrane and a fibrous capsule. inversion: combination of supination, adduction and plantar flexion.. eversion: combination of pronation, abduction and dorsiflexion. compound joint: made up of two or more bones and/or joints. uniaxial joint: 1 degree of freedom. hinge joint: monaxial; flexion/extension.

syndesmosis: fibrous connection between a concave and convex surface.

condyloid joint: allows all forms of angular movement except axial rotation.

Fundamentals of the Foot and Ankle: Joint Classification Joint

talocrural (ankle) proximal tibiofibular distal tibiofibular subtalar transverse tarsal tarsometatarsal metatarsophalangeal interphalangeal

Bones involved
talus, tibia and fibula proximal tibia and fibula distal tibia and fibula talus and calcaneous talus, navicular, calcaneous and cuboid metatarsals, cuneiforms and cuboid metacarpal and proximal phalanx adjacent phalanges

Type
synovial; hinge synovial syndesmosis uniaxial compound synovial condyloid; synovial synovial; hinge

Fundamentals of the Foot and Ankle: The Arch

The arch, also referred to as a twisted osteoligamentous plate, is formed by the configuration of bones and ligaments in the foot. The arch plays a role in both mobility and stability. In mobility, the arch acts as a shock absorber and allows the foot to adapt to changes in terrain. In stability, it allows for weight distribution through the foot during weight bearing and converts foot to a rigid lever when pushing off during gait. The plantar fascia tightens during extension at the metatarsophalangeal joint. This tightening results in a shortening of the plantar fascia that keeps the midfoot and hind foot locked in an supinated position as the heel lifts off the ground. This is known as the windlass mechanism.

Bony Anatomy

Bony Anatomy: The Ankle

The ankle joint or talocrural joint is a synovial hinge joint that is made up of the articulation of 3 bones. The 3 bones are the tibia, the fibula and the talus. The articulations are between the talus and the tibia and the talus and the fibula. The mortise is the concaved surface formed by the tibia and fibula. The mortise is adjustable and is controlled by the proximal and distal tibiofibular joints. The talus articulates with this surface and allows dorsiflexion and plantar flexion.

Anterior View

distal tibiofibular joint

TIBIA Tibia

Mortise Fibula
tibiotalar articulation

Talus
talofibular articulation

Bony Anatomy:
Talocrural joint: Most congruent joint in the body. It allows 1 of freedom: dorsiflexion and plantar flexion.
Tibia

In open chain activity (non-weight bearing), the convex talus slides posteriorly during dorsiflexion and anteriorly during plantar flexion on the concave tibia and fibula. In closed chain activity (weight bearing), the tibia and fibula move on the talus. Total talocrural joint motion is approximately: plantar flexion: 30-50 dorsiflexion: 20

Mortise Fibula

talocrural joint
Talus

Bony Anatomy:
Subtalar joint: Also known as the talocalcaneal joint. It is a triplanar, uniaxial joint which allows 1 of freedom: supination (closed packed position) and pronation (open). Supination is accompanied by calcaneal inversion (calcaneovarus) and pronation is accompanied by calcaneal eversion (calcaneovalgus). Total subtalar joint motion is approximately: inversion: 20 eversion: 10
Fibula

Tibia

subtalar joint

Talus

Calcaneous

Bony Anatomy: The Foot

Lets identify the bones of the foot. Notice that the great toe only has a proximal and distal phalange. There are also 2 sesamoid bones (not shown) located under the 1st MTP joint. The toes are also known as rays. The great toe is the 1st ray, the next toe is the 2nd ray, the middle toe is the 3rd ray, the next lateral toe is the 4th ray and the little toe is the 5th ray.
distal phalange middle phalange

proximal phalange

1st ray

2nd ray

3rd 4th ray ray

middle cuneiform

metatarsal
5th ray

medial cuneiform navicular

lateral cuneiform

cuboid

talus

calcaneous

Bony Anatomy:
Transverse tarsal joint: Also known as the midtarsal joint. It is a compound joint which allows compensation between the hind foot and fore foot on uneven terrain. It is made up of four bones (talus, calcaneous, cuboid and navicular) and two joints (talonavicular and calcaneocuboid).
transverse tarsal joint

Bony Anatomy:
Tarsometatarsal joint: Plane synovial joint formed by articulations with: 1st metatarsal and medial cuneiform 2nd metatarsal and middle cuneiform 3rd metatarsal and lateral cuneiform 4th and 5th metatarsals and cuboid Continues the compensating movement available at the transverse tarsal joint once the maximum range of motion of that joint has been reached.

tarsometatarsal joint

Bony Anatomy:
Metatarsophalangeal joint: Also known as the ball of the foot. It is a condyloid synovial joint with 2 of freedom: flexion/extension and abduction/adduction. Total MTP joint motion is approximately: great toe flexion: 0-45 toe flexion: 0-40 great toe and toe extension: 0-80
metatarsophalangeal joint

Bony Anatomy:
Interphalangeal joint: IP joints are synovial hinge joints with 1 of freedom: flexion/extension.
interphalangeal joint

Total IP joint motion is approximately: IP flexion of great toe: 0-90 PIP flexion: 0-35 DIP flexion: 0-60 great toe and toe extension: 0-80

Positioning

Positioning: General Guidelines remove any jewelry that will interfere with the anatomy being
radiographed. make patient as comfortable as possible; some positions that the patient must conform to and maintain in order for a diagnostic image to be obtained can be difficult due to disease process, trauma, etc. It is important to keep that in mind when positioning patients for an exam.

always shield when possible; for the purpose of this program, shielding
should always be utilized for radiography of the foot and ankle.

use collimation; at minimum, collimation should not exceed the cassette size.

the body part should be parallel to the film; the central ray (centering)
should be perpendicular (90) to the body part and the film.

Lead markers should be used to identify RIGHT or LEFT.

Positioning: AP foot Place foot flat onto the casette. Angle tube 10 toward the heel (calcaneus). Center to the base of the 3rd metatarsal. Include toes, metatarsals, navicular, cunieforms and cuboid.

Positioning: Oblique foot Place foot onto the casette at a 30-45 angle medially.
(45 is recommended)

Center to the base of the 3rd metatarsal. Include the entire foot and talus.

Positioning: Lateral foot Place foot onto the cassette for a mediolateral projection (recommended). Center to the medial cunieform (base of the 3rd metatarsal). Include the entire foot and 1 inch of distal tibia and fibula.

Positioning: AP toe Place foot flat onto the cassette. Angle tube 10-15 toward the heel. Center to the appropriate MP joint. Include the entire toe and of the metatarsal.

Positioning: Oblique toe Place foot onto the cassette at a 45 angle medially. Center to the appropriate MP joint. Include the entire toe and of the metatarsal.

Positioning: Lateral toe Place foot onto the cassette for a lateromedial projection of the 1st, 2nd, and 3rd toes and a mediolateral projection of the 4th and 5th toes. Center to the IP joint for the 1st toe and the appropriate PIP joint for the other toes. Include the entire toe (phalanges).

Positioning: AP ankle Place ankle onto the cassette. (the intermalleolar line will not be
parallel in a true AP projection).

Center between the malleoli. Include the distal third of the tibia/fibula and proximal half of the metatarsals.

Positioning: Oblique ankle Place ankle onto the cassette at 45 of medial rotation. Center between the malleoli. Include the distal third of the tibia/fibula and proximal half of the metatarsals.

Positioning: AP mortise Place ankle onto the cassette at 15- 20 of medial rotation. Center between the malleoli. Include the distal third of the tibia/fibula and proximal half of the metatarsals.

Positioning: Lateral ankle Place ankle onto the cassette for a mediolateral projection. (recommended) Center to the medial malleolus. Include the calcaneus, talus, tarsals and the base of the 5th metatarsal.

Positioning: Axial calcaneous Place ankle onto the cassette with the heel close to the bottom edge. Dorsiflex until plantar (bottom) surface of the foot is perpendicular to the cassette. (assistance may be necessary to
achieve this).

Angle tube 40 cephalad (cross-hairs seen on the bottom of the foot). Center to the base of the 3rd metatarsal. Include entire calcaneus to the talocalcaneal joint.

Due to the reproduction quality of this x-ray to fit the format of this tutorial, the talocalcaneal joint is not visualized.

Positioning: Lateral calcaneus Place ankle onto the cassette for a mediolateral projection. Center to 1 inches below the medial malleolus. Include the calcaneus and talus.

Technical Guidelines

Technical Guidelines:
Radiography of the foot and ankle is done at a 40 inch SID (source image distance). Keep the body part as close to the cassette as possible in order to reduce OID (object image distance). Radiographs of the ankle and foot are of better diagnostic quality when an extremity cassette is utilized. CR (computerized radiography) does not use conventional cassettes or film. Instead, a digitized plate is utilized which can be programmed to act like an extremity cassette. The difference is, however, that it is advised to only put one image per cassette. Multiple images on one cassette do not always appear properly and are difficult to window correctly. Although x-ray machines vary, the general kVp ranges for radiography of the ankle and foot is between 50-65 kVp. Adjustments in kVp and MAs should be considered in cases involving splints, casts, wraps, swelling, braces, etc.

MRI

MRI: Overview A comprehensive explanation of MRI physics is outside the scope of this program but in order to appreciate the following slides and gain the most value from them, a simplistic overview is provided.

Magnetic Resonance Imaging (MRI) is an imaging process that utilizes a magnetic field to magnetize tissues of the body in order to create a radio frequency signal (RF) that will, with the assistance of coils and a computer, produce an image. The magnetic field primarily affects tissues with an adequate amount of hydrogen. A high concentration of hydrogen will produce a strong signal and a bright area on the image while a low concentration will produce little or no signal. No signal will produce a black area with the signals in between producing gray areas, contrast.

MRI: Tissue Characteristics and Contrast: One advantage to MRI is the ability to utilize the variety of tissues in the body to produce contrast. The tissues of the body are divided into three characteristics: T1, PD and T2. Images produced in MRI are often described as being T1, PD or T2 weighted. Lets use the diagram below to help define these terms as they relate to the image that is produced. T1: on a T1 weighted image, fat is bright and water is dark. PD: on a proton density image, water is bright and fat is dark but the contrast between the two is less define. T2: on a T2 weighted image, water is bright and fat is dark but the contrast is greater.
fat
T1
PD

bright water
T2

water T1 PD

fat T2

dark

MRI: Axial T1
The axial view of the foot in MRI is comparable to the AP view of the foot in x-ray. The image to the right is one slice of an axial sequence.
1st metatarsal

middle cuneiform

medial cuneiform

lateral cuneiform

navicular

talus

Achilles tendon

MRI: Axial T1
The axial view of the foot in MRI is comparable to the AP view of the foot in x-ray. The image to the right is one slice of an axial sequence.

1st metatarsal

medial cuneiform abductor hallicus ms.

cuboid

calcaneus

Achilles tendon

MRI: Sagittal T2
The sagittal view of the foot in MRI is comparable to the lateral view of the foot in x-ray. The image to the right is one slice of a sagittal sequence.
Achilles tendon tibia talus metatarsal fluid

calcaneus

MRI: Coronal T2

The coronal view of the foot in MRI has no comparable view in xray. The coronal slice is similar to slices in a loaf of bread. The image to the right is one slice of a coronal sequence.

1st metatarsal

3rd metatarsal

4th metatarsal 5th metatarsal

MRI: Coronal T2

The coronal view of the foot in MRI has no comparable view in xray. The coronal slice is similar to slices in a loaf of bread. The image to the right is one slice of a coronal sequence.

2nd metatarsal

1st metatarsal

3rd metatarsal 4th metatarsal 5th metatarsal

Common Clinical Findings

Common Clinical Findings: Ligaments:

The MCL (medial collateral ligaments) is made up of the three fan-shaped ligaments attached to the distal tibia, also known as the deltoid ligament. This group of ligaments limits valgus stresses on the ankle. This is a fairly strong group and not commonly torn.

Medial ligaments:
deltoid ligament

spring ligament (plantar calcaneonavicular)

The function of the spring (or plantar calcaneonavicular) ligament is to maintain the arch of the foot.
The plantar fascia (aponeurosis) is a sheet of connective tissue that runs from the calcaneous to the proximal phalanges.
plantar fascia (aponeurosis)

Common Clinical Findings: Ligaments:

The LCL (lateral collateral ligaments) is made up of the anterior talofibular ligament, the posterior talofibular ligament and the calcaneofibular ligament. This group of ligaments limits varus stresses on the ankle. The weakest and most commonly torn of this group is the anterior talofibular ligament. The function of the long plantar and short plantar(or plantar calcaneocuboid ) ligaments is to maintain the arch of the foot. The bifurcate ligament attaches from the calcaneous to the navicular and the cuboid. The dorsal calcaneocuboid ligament is found lateral and distal to the bifurcate ligament and also attaches from the calcaneous to the cuboid.

Lateral ligaments:
posterior talofibular ligament anterior talofibular ligament bifurcate ligament calcaneofibular ligament dorsal calcaneocuboid ligament long plantar ligament short plantar ligament

Common Clinical Findings:

Now that weve reviewed and understand the basic structure and function of the foot and ankle, lets review some of the common clinical findings.

1. Achilles Tendonitis: -inflammation caused by repetitive motions involving the Achilles tendon. -RX: rest/immoblization, ice, ultrasound, NSAIDs, massage, stretching, exercise. 2. Achilles Tendonosis: -progression of the inflammation of the Achilles tendon to degeneration of the tendon. -RX: rest/immoblization, ice, ultrasound, NSAIDs, massage, stretching, exercise, surgery.

Common Clinical Findings:

3. Ankle Sprain: -injury involving one or more ligaments in the ankle. -severity dependent upon number of ligaments involved, stretched vs torn and to the degree the ligament is torn. -RX: rest/immoblization, ice, NSAIDs, compression wrap, elevation, surgery. 4. Ankle Fracture: -injury involving one or more bones of the ankle. -severity dependent upon number of bones involved, displaced vs non-displaced, protruding through skin. -RX: rest/immoblization, ice, NSAIDs, compression wrap, elevation, surgery.

Common Clinical Findings:

5. Plantar Fascitis: -inflammation to the plantar fascia resulting in heel pain due to prolonged non-weight bearing (sitting) in some cases and prolonged weight bearing (standing) in others. -RX: stretching exercises, ice, rest, NSAIDs, orthotics and/or shoe modification. 6. Pes Planus: -also known as flat foot; partial or complete loss of arch. -RX: weight loss, rest, NSAIDs, orthotics and/or shoe modification, surgery.

Common Clinical Findings:

7. Chronic Instability :
-usually caused by a lateral ankle sprain that has not healed properly and/or repeated ankle sprains resulting in laxity in the LCL. -RX: strengthening exercises, bracing, NSAIDs.

8. Osteoarthritis : -breakdown and loss of cartilage in one or more joints. -could be caused by flatfoot, jamming toe(s), fracture, severe sprain. -RX: strengthening exercises, rest, NSAIDs, orthotics and/or shoe modification, bracing, steroid injections, surgery.

Common Clinical Findings:

9. Pes cavus: -excessively supinated foot as a result of a high arch -loss of shock absorption ability or adaptation to uneven terrain -RX: questionable results with conservative intervention.

Common Clinical Findings:

fracture of the lateral malleolus

Common Clinical Findings:

amputation of great toe

Common Clinical Findings:

fracture of base of 5th metatarsal

fracture of base of 5th metatarsal

fracture of cuboid

fracture of cuboid

Conclusion:
Radiography of the foot, ankle and toes is done at a 40 inch SID (source image distance). Keep the body part as close to the cassette as possible in order to reduce OID (object image distance). Although x-ray machines vary, the general kVp ranges for radiography of the wrist and hand is between 50-65 kVp. Adjustments in kVp and MAs should be considered in cases involving splints, casts, wraps, swelling, braces, etc. The body part should be parallel to the film and the central ray (centering) should be perpendicular (90) to the body part and the film unless otherwise indicated. Always shield when possible; use collimation, identify LEFT or RIGHT by utilizing lead markers, remove jewelry that may interfere with anatomy and be conscious of patient comfort when positioning.

Test:
There are 60 questions on this test. All answers can be found within the context of this program. The hint button located next to each question will provide you the information needed to answer the question. At any time during the test you may skip a question and return to it later. You must successfully answer 70% of the questions in order to receive credit for the course. To access the test, please close out of this course by clicking the x in the top right corner.

Good luck!!!

Norkin, Cynthia C. and Levangie, Pamela K.; Joint Structure & Function: A Comprehensive Analysis, Second Edition, F.A. Davis Co. Philadelphia, PA.1992 Malone,Terry R., McPoil, Thomas, Nitz, Arthur J.; Orthopedic and Sports Physical Therapy, Third Edition, Mosby-Year Book Inc. St. Louis, MS. 1997 Hislop, Helen J. and Montgomery, Jacqueline; Daniels and Worthinghams Muscle Testing: Techniques of Manual Examination, Sixth Edition, W.B. Saunders Co. Philadelphia, PA. 1995 Stalheim-Smith, Ann and Fitch, Greg K.; Understanding Human Anatomy and Physiology, West Publishing Co. St. Paul, MN. 1993 Thomas, Clayton L.; Tabers Cyclopedic Medical Dictionary, Seventeenth Edition, F.A. Davis Co.Philadelphia, PA. 1993 Bontrager, Kenneth L.: Textbook of Radiographic Positioning and Related Anatomy, Fourth Edition, Mosby Inc. St. Louis, MO. 1997 Tortora, Gerard J. and Grabowski, Sandra R.; Principles of Anatomy and Physiology, Ninth Edition, John Wiley & Sons, Inc New York, NY. 2000 Footphysicians.com. Healthy Feet for an Active Life. Foot & Ankle Information. 2005 15. Feb. 2006 http://footphysicians.com/footankleinfo Stoller, David W.; Magnetic Resonance Imaging in Orthopaedics and Sports Medicine, J.B. Lippincott Co. Philadelphia, PA. 1993 Sprawls, Perry; Magnetic Resonance Imaging Principles, Methods, and Techniques, Medical Physics Publishing, Madison, WI. 2000

References: